UNIT XIV

Introduction

IR suites are real-time decision-making environments in which lack of flu- ency can be troublesome not only for the non-native English-speaking radiologist but for anybody else in the laboratory, the patient included.

This is the reason why we have dedicated a complete unit to interventional radiology.

When you enter an IR suite your listening skills are much more impor- tant than your fluency; nobody is expecting you to say too much but everybody takes for granted that you understand them, and that is not al- ways true. You will find no difficulty when the conversation is on the pathology itself; in the first few days many jargon terms, acronyms, and abbreviations can be tricky but, with a bit of help, you will soon feel rea- sonably confident.

Do you know, for example, what a SOAP note is? If you haven't worked in an American hospital, probably not. SOAP stands for (Subjective com- ments on the patient, Objective findings, Assessment, and Plan) and SOAP note refers to the standard follow-up chart entries.

One of the main problems of non-native English-speaking interventional radiologists working in English-speaking IR suites is the lack of knowledge of basic vocabulary, jargon terminology, acronyms, abbreviations, and set phrases.

Let us begin with this simple conversation that may have happened hun- dreds of times in IR suites. Familiarity with conversations such as the fol- lowing will help in our first days in an English-speaking IR suite.

· Radiologist getting ready for case, speaking to IR technologist: ªI'll be in as soon as I get the cap, facemask, and booties on.º

· IR technologist: ªI'll have your gown ready for you. What size gloves do you take?º

· Radiologist: ªI usually take 8's but I'm going to double-glove for this case, so I'll take 8 under and 8 1/2 on top. Thanks.º

The first thing a foreigner notices in an IR suite is that he/she is not famil- iar with terminology regarding garments since he/she has not asked for

Unit XIV Interventional Radiology

garments in English before and because virtually nothing has been written on booties, masks, caps, gowns, etc.

In the following pages we will go over several sentences typical of an IR suite. Those who have not worked in an IR suite abroad and are not going to do so in the future may not see the point in reviewing so many easy set phrases; these sentences are indeed quite easy to understand for an inter- ventional radiologist independently of his English level.

Our advice is try to read them aloud. By doing this not-that-simple ex- ercise you will immediately notice that you may not be confident in read- ing aloud and pronouncing correctly some of the sentences you used to de- spise as simple. The best way to become familiar with the listening, pro- nunciation, and spelling of these sentences is to write them down and read them aloud.

When, during your first days in a foreign IR suite, you hear some of these sentences uttered by native speakers you will realize how important it was to have heard the sentences before, and you should already have practiced the first sentences you have to say yourself.

Garments

Tools and devices are usually well known by foreign radiologists since they have read about them in the literature. Garments are a different issue.

Since garment terminology is so engrained in the core of the subspecialty, it is quite difficult to find written garment names; no article is going to say a word on scrubs, booties, masks, lead aprons, radiation badges ...

The most common formula to ask for anything in this environment is:

· Can I have ...?

Everyone who has rotated in an English-speaking IR suite has felt the need to ask for garments:

· Where are the lead aprons?

· Do we have lead aprons?

· This lead apron is too small. Can I have a larger one?

· Can I have a face mask?

· Could you give me a hood?

· Can you tell me know where the shoe covers are.

· I'll need a pair of lead gloves.

· What size gloves do you take? Eight.

· I'm going to double-glove for this case.

· I'll take 8 under and 8 ½ on top.

· My scrubs top is soaked. I need to change it.

· There is a blood stain on my scrubs pants (UK trousers).

· I left my radiation badge in my locker.

Look at the schematic representation on the following page in which we have included some of the most common IR garments.

Tools and Devices

Once you are properly dressed, you will have to ask for tools and devices.

Since most tools and devices are known beforehand, we give you a few ex- amples of usual requests and common formulas to ask for guides, stents, catheters ...:

· Can I have a 0.035 guidewire?

· Can I have a hydrophilic guidewire?

· Can I have a 5F introducer?

· Can I have a 16 G needle?

· Give me a 10F nephrostomy tube, please.

· Give me an angled Amplatz guidewire, please.

· I'd rather use a pig-tail catheter.

· The foreign body seems to have a free end; I'll use an Amplatz goose neck snare.

· Can I have a torque vise?

· Can I have a stiffer guidewire, please?

Talking to the Patient

ªDon't breathe don't moveº is probably the commonest command in an IR suite.

· Keep still.

· Don't breathe don't move.

· Push as if you were going to have a bowel movement (Valsalva maneu- ver).

· Take a deep breath and bear down as if you are going to have a bowel movement (Valsalva maneuver).

· Let me know if this hurts (to check if the local anesthetic is working properly).

· Let me know if this stings (to check if the concentration of the local an- esthetic in sodium bicarbonate is adequate).

· Do you feel a warm sensation during injection? (to check if the concen- tration of local anesthetic in sodium bicarbonate is adequate).

· You will feel a burning sensation in your stomach during injection of the contrast material. It's nothing to worry about.

Talking to the Patient 249

1. Cap, 2. Mask, 3. Thyroid shield, 4. Lead Apron, 5. Gloves, 6. Radiation badge, 7. Scrubs,

8. Clogs, 9. Gown

· Breathe in deeply and hold your breath.

· Breathe in deeply.

· Breath out deeply and hold your breath.

Talking to the Patient's Family

Before the Procedure

· Your father/husband/mother/wife/son/daughter is about to undergo an interventional radiology procedure (arteriography, PTA ...). It will take approximately ... minutes. The procedure does not need a general anes- thetic, only local anesthesia, so your father (etc.) will remain conscious.

I will let you know how the procedure went as soon as we finish.

After the Procedure Good News

· Everything has gone fine from a technical point of view; we will look carefully at the images and the report will be sent to your father's (etc.) referring physician. In a few minutes you will see your father (etc.). He is doing fine. Please make sure he does not move his right leg for 24 hours.

Bad News

· I am afraid your father's condition is critical. He will be transferred to the ICU.

· Unfortunately, we have not been able to cross the stenosis so the patient will be transferred to the Department of Vascular Surgery where he will be operated on on an elective basis.

· There has been a serious complication. Your father is being transferred to the operating room where he will be operated on now. We (the sur- geon and myself) will inform you of the situation as soon as the opera- tion is finished.

Talking to the Patient's Family 251

Teaching Residents

These are some of the most common commands given in IR suites:

· Prep the patient.

· Drape the patient.

· Make sure that the patient's groin has been shaved, scrubbed and draped.

· Has the puncture site been scrubbed?

· Locate the right common femoral artery (RCFA) by palpation.

· Locate the left humeral artery by palpation.

· Puncture the artery.

· Do not force the wire.

· Inject local anesthetic as deeply as possible and don't forget to aspirate before injecting.

· Tape the lower abdominal pannus back away from the groin.

· Nick the skin with a small blade.

· Use a hemostat to fluoroscopically check the proper position of the in- tended entry site.

· The skin entry must be over the lower femoral head and the puncture site over the medial third of the femoral head.

· Advance the needle in a single forward thrust.

· Advance the needle by about 2±3 cm.

· Remove the stylet.

· Retract the needle slowly.

· Gently retract the syringe while keeping the position of the needle firmly fixed.

· Have you flushed the cath (catheter)?

· Have you checked for free backflow?

· Don't lose the wire.

· Hold the wire.

· Wipe the guidewire.

· Manipulate gently.

· Don't forget that the catheter tip migrates cephalad 2±3 cm after upright positioning.

· Once the dilator is introduced over the wire, exchange it for the pigtail catheter.

· Avoid axillary artery puncture because of the proximity to the brachial plexus.

· The stent is not patent.

· The ureter has been perforated.

· There is a clot in the renal pelvis.

· Remove the nephrostomy tube over the wire.

· The initial stent positioning was not appropriate.

· The stent sizing is appropriate.

· Exchange the micropuncture dilator for a peel-away sheath.

· The peel-away sheath is kinked at a sharp turn.

· Have you aspirated both lumens?

· Is there free blood return?

· Peel away the sheath.

· Introduce the catheter over the wire.

· Do not persevere with catheter manipulation.

· We could not cross the lesion.

· The coil is misplaced.

· The coil has migrated into the central venous circulation. Give me a snare device.

· Don't worry. Venous perforations are usually self-limiting.

· Tunneled catheters may have staggered or aligned tips.

· If there is no pyonephrosis, use an 8F nephrostomy tube.

· Dilate the tract up to the required French size.

· Avoid puncturing extrahepatic ducts.

· After crossing the stenosis, give 2500 IU of heparin IA.

· Size the balloon diameter equal to the adjacent normal vessel measured on cut-film arteriography.

· Cross the stenosis gently.

· Extra care must be taken with hydrophilic Glidewire to avoid dissection.

· Retract the balloon-catheter leaving the guidewire across the lesion.

· Keep the balloon deflated by suctioning with a large-bore syringe.

Talking to Nurses

· May I have my gown tied?

· Would you tie my gown?

· Tie me up, please.

· Dance with me (informal way of asking to have your gown tied).

· I'll go scrubin a minute.

· Give Dr. Ross a pair of shoe covers.

· Give Dr. Ross a thyroid shield.

· Give Dr. Ross a lead apron.

· Mary, I forgot my thyroid shield. Could you put one on me?

· Is the patient monitored yet?

· Dr. Cole, there is a phone call for you. It's Dr. Viamonte. Tell him I'll call back later; I can't break scrub now.

· May I have another pair of gloves, please?

· May I have a pair of lead gloves?

· We've had a complication. Page the thoracic surgeon.

Talking to Nurses 253

Talking to Technologists

· Can I have this image magnified, please?

· Could you please collimate the image to minimize my hand exposure?

· An LPO 45 degrees, please.

· Right posterior oblique 45 degrees (side of interest down).

· Film at 4 to 6frames per second during suspended respiration in antero- posterior DSA.

· Road mapping, please.

The IR's Angiographic Equipment

· The generator provides the electrical energy from which X-rays are gen- erated and contains the circuitry needed to provide a controlled and stable radiation output. The mid- to high-frequency inverter is the most popular generator design.

· The X-ray tube is made of a tungsten filament cathode and a spinning anode disk with a tungsten surface. Electrons go from the cathode to the anode where they are stopped by its tungsten surface.

· The image intensifier (II) converts the X-ray pattern that penetrates the patient to an intensified image. Its fields of view range from 4 to 16 inches depending on the magnification factor.

· The patient table is usually made of carbon fiber to provide enough strength to support an adult patient while minimizing the attenuation of X-rays.

· The gantry stand contains both the X-ray tube housing with collimator and the image intensifier/imaging chain.

· High refresh-rate TV monitors are used to reduce flickering of the image created within the digital TV camera.

· Contrast injectors allow the adjustment of injection volume, peak injec- tion rate, and acceleration to peak rate. Contrast injector arms can be ceiling-suspended or mounted on the table. The injector control unit can be on a pedestal in the procedure room or rack-mounted in the control area.

Some Common ªOn Callº Orders for Nurse Units

These are some of the commonest orders for nursing IR units. Non-native

English-speaking interventional radiologists must be familiar with them in

order to be able to write them down on the chart.

Patient Preparation

· Premedicate with diazepam (Valium) 10 mg PO (oral intake) given on- call to angiography (optional). Reduce dose for elderly and pediatric pa- tients.

· Obtain informed consent.

· Patients must void urine before leaving the ward for the angiography suite.

· Transfer the patient to the angiography suite with his/her identification plate, chart, and latest laboratory reports on chart.

· The front cover of the chart should list all precautionary measures needed to protect the patient (especially if immunocompromised) and personnel (who may come into contact with patients with infectious dis- eases).

· Clear fluids only after midnight (for morning appointment).

· Clear fluids only after breakfast (for afternoon appointment).

· Insert Foley catheter.

· Vigorous hydration (NSS at 125 ml/h).

· Prophylactic antibiotics IV.

· Instruct patient to use PCA pump.

· Laboratory check: Hgb/Hct, platelet count, PT/PTT, BUN, and Cr.

· Establish a peripheral IV.

Postprocedure Management

· Bed rest for 6 to 8 hours, with puncture site evaluation.

· Vigorous hydration (NSS 3 l/34 h) until oral intake is adequate.

· Stop analgesics and remove Foley catheter 24 hours after the procedure.

· Monitor patient in the recovery room for 6 hours prior to discharge.

· IV narcotics (prn).

· Forward-flush the drainage catheter with normal saline every 48 hours.

· Change the dressing around the drainage catheter every 48 hours.

· Leave the catheter to gravity drainage without flushing.

· Remove catheter when there is drainage of less than 20 ml/day and vital signs return to normal.

· Follow-up ultrasound scan in 24 h.

Some Common ªOn Callº Orders for Nurse Units 255

IR Chart Entries Standard Format

An example of a daily chart entry following uterine artery embolization (UAE) would be a SOAP note (Subjective comments, Objective findings, As- sessment, Plan), as follows:

IR PN-R3

S

: Pt without complaints. No nausea or pain.

O

: T (max) 37.2, 82 bpm, BP: 122/78, u.o = x ml/hour Pt in NAD

Chest: CTA b

Abdo: benign, S NT, NAD

Groin: No hematoma. Dressing c/d/i

Ext: Warm 2+ DP, 2+ PT. Neuro sensation intact.

A/P

: Post UAE day 1

1. Pt doing well post UAE. Pain well controlled.

2. Planning d/c to home this morning.

1

The first line denotes the service authoring the note and the person writing the note. In this example, ªIR PN-R3º indicates that interventional radiology is the service authoring the progress note (PN). ªR3º refers to the person writing the note. Typically, R means ªresidentº followed by the training year (3). Attending physicians will usually write ªStaffº.

2

ªSº is a summary of the patient's subjective comments.

3

ªOº is a summary of objective findings (including vital signs and urine/drain output) and physical examination (NAD no acute distress; CTA b clear to auscul- tation bilaterally; S NT soft, nontender; NAD normal active bowel sounds; c/d/i clean dry intact, DP dorsalis pedis artery; PT posterior tibial artery).

4

ªA/Pº is a summary of the assessment and plan (d/c discharge).

Progress Note

While in-house, patients are followed at least daily. Daily progress notes (PN) follow the same format. Many in-house patients, particularly unit patients, have complex issues. While the IR service needs to be aware of all issues, the progress note is focused on the issues that directly impact our care.

IR PN-R3

S: Pt intubated and sedated.

O: T 36.2±38.4 (presently 37.0), HR 78±102 (presently 86), BP 112±132/

72±88 (presently 122/82), u.o=x ml/hour, percutaneous cholecystost- omy output: xx ml/12 hours

Pt intubated

Percutaneous cholecystostomy site c/d/i. Dark green output (volumes as above).

Abdomen: S NT. Diminished bowel sounds.

Intraprocedure cultures pending.

A/P: Post Perc Chole day 2.

1. Drainage catheter functioning without difficulty. Continue current care.

2. Will continue to follow daily. Please page xxxx if any questions arise.

IR Procedure Note Standard Format

IR procedure note: ____

Date/Time: ____

Inpatient/Outpatient: ____

History/Indications: ____

Consent: ____ (from patient or from appropriate family member if patient unable to consent)

Radiologist: ____

Guidance modality: ____ (CT/US/fluoroscopy/MR) Medications given: ____ (includes dose)

Needles/Catheters/Device used: ____ (includes device number) Findings: ____

Specimen sent: ____

Complication: ____ (includes steps taken, management and/or person con- tacted to assist in management)

Disposition: ____ (to floor/ICU or holding followed by home if outpatient procedure)

Some Common ªOn Callº Orders for Nurse Units 257

Example 1

IR procedure note: CT guided drainage catheter placement Date/Time: March 3, 2005

Inpatient/Outpatient: Inpatient 6D

History/Indications: 32 y.o. woman involved in MVC with LUQ intraab- dominal abscess post splenectomy.

Consent: Written, informed consent obtained from patient.

Radiologist: Dr. Smith Guidance modality: CT

Medications given: Versed 2 mg, Fentanyl 200 mcg

Needles/Catheters/Device used: 22 gauge ´ 10 cm needle, 14 French flexima (serial no. 123456)

Findings: Thick-walled low-density, collection in LUQ contains thick, dark- brown fluid

Specimen sent: 10 ml of dark brown fluid for GS and culture. Total 150 ml aspirated

Complication: Trace left pneumothorax. Patient remained hemodynamically stable through the procedure. 4 hours postprocedure CXR showed no PTX.

Primary physician, Dr. Jones, informed of trace PTX. Plan made for close observation with repeat CXR if clinical symptoms develop.

Disposition: To floor 6D Example 2

IR procedure note: Right IJ (internal jugular) HD (hemodialysis) catheter placement

Date/Time: March 4, 2005 Inpatient/Outpatient: Outpatient

History/Indications: 63 y.o. male with h/o DM and ESRD in need of venous access for hemodialysis.

Consent: Informed, written consent obtained from patient.

Radiologist: Dr. Smith

Guidance modality: Fluoroscopy, imaging time <60 sec Medications given: Fentanyl xx mcg, Versed xx mg

Needles/Catheters/Device used: MedComp Serial no. 123456

Findings: HD catheter placed via right IJ, tunneled to right anterior chest wall. Catheter tip is in mid RA. No kink along catheter course. No pneu- mothorax on fluoroscopy. All lumens draw blood back briskly and were terminally flushed with xxx U/cc of heparin.

Specimen sent: None Complication: None Disposition: To dialysis Example 3

IR procedure note: Right percutaneous renal biopsy Date/Time: March 2, 2005

Inpatient/Outpatient: Inpatient 5D

History/Indications: 54 y.o. male s/p left nephrectomy in 1997for RCC.

Newly diagnosed lung adenoCA. New right renal mass.

Consent: Informed written consent obtained from patient.

Radiologist: Dr. Smith Guidance modality: CT

Medications given: Fentanyl xx mcg, Versed xx mg

Needles/Catheters/Device used: ... (includes device number) Findings: ...

Specimen sent: Three samples reviewed by cytopathologist at time of biopsy.

Complication: Trace right subcapsular hematoma. Patient remained hemo- dynamically stable through the procedure. Primary physician, Dr. Jones, in- formed of right renal subcapsular hematoma. Plan made for close observa- tion with hematocrit check/repeat CT if clinical symptoms develop.

Disposition: To floor 5C Contrast Reactions

For contrast reactions, a form rather than chart entry is used. The infor- mation is similar and includes:

· Type and volume of contrast given

· Type and severity of reaction

· Action taken

· Future recommendation

Some Common ªOn Callº Orders for Nurse Units 259

If the form were to be written, an example would be:

Date/Time: ...

Pt Smith (MR no. 123456) developed a mild facial rash following the ad-

ministration of 100 ml Ultravist 300. Patient remained hemodynamically

stable and had no dyspnea. Given the mild reaction, no pharmaceutical ac-

tion was taken. Patient was kept in observation for one hour, during which

the rash resolved with no residual symptoms. Patient was asymptomatic at

time of discharge to home. ER warning was given and contact pager of the

radiologist on call provided. Patient also provided with Contrast Reaction

Card for future reference. Entry of event made into medical record. Patient

instructed that subsequent studies should (a) be done without contrast

agent, (b) be done with proper premedication, or (c) be done using alter-

native modality requiring no Ultravist. Risks and benefits of study should

be discussed with referring physician and radiologist at time of study.